Duell, Rosetta NEW YORK STATE DEPARTMENT OF HEALTH v Vit Burial - Transit Permit
i ; Records Section
Name Firs 1 Middle Last Sex
P�e,rTA �W� v�t-L fr
Date of Death Age If Veteran of U.S. Armed Forces,
6 y-i 5--?-D/ V ez War or Dates
i of Death Hospital, Institution or-1- P
Cit' Town or Village (c'L ,s Street Address I H Ai'' Qr t,F
a anner of Death Natural Cause Accident 0 Homicide 0 Suicide Undetermined D Pending
IL/ Circumstances Investigation
W Medical Certifier Name Titi
t4 _S'Uz �,r. l 4 D
Address
1-7 d I/UAti �• &—F—A), FAQ-Ls, Ai/ 12.10
D - 'ownCertificate Filed et----A)--r
� , w *Ste/ District Number Register N e
.City, or Village G',& / i %`/
=urial Dae7"f!7—col L priletea'` . i o(a f era. rC. 1•1-1 j/
DEntombment Address
OCremation (_,Ait-'r=kcr/cRa ., /C)/ ___
Date - Place Removed
Removal and/or Held
2 and/or
Address
C')
Hold
0 Date Point of
cti 0 Q Transportation Shipment
a by Common Destination
Carrier
Ell Disinterment Date " Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to �,� -�� A Registration Number
Name of Funeral Home +` 0--0► --rt +( Q t o'7f•
Address
13o Pititti N CT., Cf' L
Name of.Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
Ltd
``: Permission is h reby granted to dispose of the human remains d cri edd bo indicated.
Date Issued w / ilv Registrar of Vital Statistics ___Git
(signature)
District Number i-6d r/ Place 6/e/25/ 4 /r /02PO /
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
4/1 7/1 4 West Glens Falls Cemetery
l� Date of Disposition Place of Disposition
2 (address)
tLI
fil Family Plot
1X. (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premis Connie L. Goedert
Z (please print)
I Signature .c t_ Title Superintendent
9 �.
(over)
DOH-1555 (02/2004)